Clinical psychologist (CP)

Qualification requirements

Clinical psychologists (CP) must meet all of the following criteria to provide services for Medicare beneficiaries:

• Hold a doctoral degree in psychology (e.g., Ph.D., Ed.D., PsyD)
  

• Licensed or certified on the basis of the doctorate in psychology by the state in which the individual practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals
  

Documentation requirements and recommendations

Providers must submit an enrollment application by:

• Completed CMS-855I form 
• Signed and dated certification statement:
  
  • The signature of the individual practitioner must be a handwritten signature (original signature not required)
  • Digital signatures (DocuSign or other software) are acceptable
  • A copy of the signature is acceptable; however, no stamped signatures can be accepted

Or: 

• Completed web application using PECOS:
• Signed and dated certification statement of PECOS web application by:
  
  • E-signing electronically or
  • Uploading a signed and dated paper certification statement

And:

• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) or its equivalent in PECOS:
  
  • Must include associated documentation (e.g., copy of a voided check or account confirmation letter on bank letterhead)
• If a provider already receives payments via EFT and is not making a change to banking information, the EFT is not required
• Physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588
• Read CMS-588 Electronic funds transfer (EFT) for more information

Additional documentation requirements (when applicable)

Medicare may require additional documentation, when applicable, to validate key information submitted on the enrollment application or to address specific issues that could affect a practitioner’s potential eligibility for enrollment unfavorably (e.g., adverse legal actions).

• Include copies of the following supporting documents, if applicable:
  
  • Copy of practitioner’s state medical license if not verifiable online
  • Copy of certification if not verifiable online
  • Certificate of completion, transcript, or diploma from accredited educational program(s) if requested
  • IRS document verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)
    
    • Applies to clinics, groups, organizations, and institutional providers
  • Final adverse legal action documentation:
    
    • Include copies of legal documents associated with any final adverse action(s) taken against the provider
    • Include copies of any legal documents showing the resolution (e.g., notifications, reinstatement letters)
  • Completed Medicare Participating Physician or Supplier Agreement (CMS-460), if applicable:
    
    • A participating provider is one who bills Medicare directly and accepts assignment for covered services as payment in full
    • Physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-460
• Good Standing Letter (GSL) – When there is no online source to verify a provider’s medical license in the U.S. Virgin Islands or Puerto Rico, the provider/supplier must supply a Good Standing Letter (GSL) or 120-Day Certification Letter from the State/Territory licensing authority:
  
  • A copy of the GSL or 120-Day Certification Letter issued by the State/Territory licensing authority must be submitted with each application received for initial enrollment, reactivations, revalidations, and change of information applications involving a license update/change
  • The GSL may have multiple names listed on the letter to show an active medical license
  • The GSL is valid if it was issued within:
    
    • 6 months of receiving the application for U.S. Virgin Islands
    • 12 months of receiving the application for Puerto Rico